Diagnosis and treatment of menorrhagia

One-third of all women experience heavy menstrual bleeding at some point in their life. In western countries, about 5% of women of reproductive age will seek help for menorrhagia annually. Half of all women who consult for hypermenorrhea have some uterine abnormality, most often fibroids (among patients under 40 years of age) and endometrial polyps (above 40 years of age). Appropriate treatment considerably improves the quality of life of these patients, and it is important to make a rigorous assessment of the patient to provide the best treatment options. This guideline provides instructions on how to examine and treat women of fertile age who have menorrhagia. The subject's own assessment of the amount of menstrual blood loss does not generally reflect the true amount. All patients should undergo a pelvic examination and, if the menstrual pattern has changed substantially or if anaemia is present, a vaginal sonography should be carried out as the most important supplemental examination. Vaginal sonography combined with an endometrial biopsy is a reliable method for diagnosing endometrial hyperplasia or carcinoma, but it is insufficient for diagnosing endometrial polyps and fibroids; these can be diagnosed more reliably by sonohysterography or hysteroscopy. Non-steroidal anti-inflammatory drugs and tranexamic acid reduce menstrual blood loss by 20-60%, and the effectiveness of a hormonal intrauterine system (IUS) is comparable with that of endometrial ablation or hysterectomy. Cyclic progestogens do not significantly reduce menstrual bleeding of women who ovulate. Treatment should be started with one of the drug therapies, i.e. the IUS, tranexamic acid, anti-inflammatory drugs, or oral contraceptive. Drug treatment should be used and evaluated before surgical interventions are considered. With an effective training and feedback system, it is possible to organise the diagnostics, medical treatment and follow-up of heavy menstrual bleeding in the primary health care setting or in outpatient clinics, which reduces the burden on specialist health care.

Physiotherapy for female stress urinary incontinence: individual therapy at the outpatient clinic versus home-based pelvic floor training: a 5-year follow-up study

AIMS

To compare the long-term effects of individual physiotherapy at an outpatient clinic, including electrical stimulation (ES), active pelvic floor muscle exercises (PFMEs), and training with a vaginal ball (VB), with home-based active PFMEs and training with a VB, in cases of female stress urinary incontinence (SUI).

MATERIALS AND METHOD

Thirty-three women with SUI (outpatient clinic group [Group I, n = 16] and home group [Group II, n = 17]) participated in the 5-year follow-up study. Both groups had an active PFME program and they used a VB during daily activities for intensive pelvic floor muscle (PFM) training. Group I was also treated at the outpatient clinic with maximal interferential ES, using frequencies varying from 10 to 50 Hz, and individually instructed exercises with biofeedback were carried out at the same time, once a week, an average of nine times in the first year. After baseline examinations, both groups visited the outpatient clinic at 4 months, 12 months, and at 5 years.

RESULTS

At 12 months, there were no statistically significant differences between the study groups in any of the outcome variables, but within the groups both the subjective and objective results were significantly better in comparison with the initial values. After 12 months, two (3%) patients in Group I continued physiotherapy and seven (41%) patients in Group II needed physiotherapy because of an unsatisfactory outcome. At 5 years, according to the urinary incontinence severity score (UISS) questionnaire, subjective discomfort had decreased in both groups (P < 0.01) and 21 of the 33 women (64%) perceived a subjective cure or improvement in their condition. The mean objective urine leakage verified by the pad test decreased from 23.0 to 1.0 g in Group I and from 13.0 to 1.0 g in Group II (P < 0.001 for both groups). The strength of PFMs tested in a standing position increased by 26% in Group I and by 19% in Group II (P values 0.001 and 0.084, respectively), and in a lying position by 28% in Group I and by 32% in Group II (P values 0.001 and 0.008, respectively).

CONCLUSIONS

Home-based PFMEs and training with a VB proved to be equally effective as once-a-week supervised therapy, and the 5-year follow-up results demonstrated a successful response in the treatment of female SUI.

Analysis of the imputed female urinary incontinence data for the evaluation of expert system parameters

We evaluated parameters for an expert system which will be designed to aid the differential diagnosis of female urinary incontinence by using knowledge discovered from data. To allow the statistical analysis, we applied means, regression and Expectation-Maximization (EM) imputation methods to fill in missing values. In addition, complete-case analysis was performed. Logistic regression results from the imputed data were reasonable. The significant parameters were mostly those that are important in the diagnostic work-up. Moreover, directions of relations between the parameters and the stress, mixed and sensory urge diagnoses were as expected. Analysis with the complete reduced data set gave clearly insufficient results. Imputed values had a moderate agreement, but odds ratios and classification accuracies of logistic regression equations were similar. Results suggest that with these data, simpler methods may be used to allow multivariate analysis and knowledge discovery, when better methods, such as EM imputation, are unavailable. Cluster analysis detected clusters corresponding to the small normal class, but was unable to clearly separate the larger incontinence classes.

Indicators of L-arginine metabolism and cardiovascular risk factors--a cross-sectional study in healthy middle-aged men

This study examines the relationship between traditional risk factors of coronary artery disease and indicators involved in the metabolism of L-arginine (plasma and urine L-arginine, plasma L-citrulline, serum creatinine and urine orotic acid). Our study population consisted of 40 healthy male volunteers aged between 35 and 55 years. We found an inverse association between serum creatinine and blood pressure, between plasma L-citrulline and blood pressure, as well as between urine L-arginine and blood pressure. We also found a positive association between plasma LDL-cholesterol and urine L-arginine and a negative correlation between plasma L-arginine and LDL-cholesterol. Orotic acid measured from urine was not associated with any of the indicators of L-arginine metabolism. Our results indicate that L-arginine metabolism is of profound significance for cardiovascular health. However, our study does not answer questions relating to causality. Further studies are needed to clarify the causal relationship between cardiovascular risk factors, especially elevated blood pressure and high LDL-cholesterol, and indicators of L-arginine metabolism.

Work ability and job demands of aging white- and blue-collar workers in 1981 and 1996

This study compared perceived work ability and job demands in 1981 and 1996. Two samples of municipal workers were formed by matching according to location (eastern Finland), occupational status (white- and blue-collar jobs), gender (men), and age (> or = 45 years). In 1981, 50 white-collar (mean age 51 [SD 3] years) and 214 blue-collar (mean age 51 [SD 4] years) workers responded. In 1996, the corresponding numbers were 43 and 54, respectively, the mean age being 50 [SD 4] years for both groups. Perceived work ability and psychological resources changed very little from 1981 to 1996, but there seemed to be a trend towards a more positive view of future work ability. General and mental job demands, in particular, seemed to be increasing among white-collar workers. The observed differences in work ability and job demands were systematically more positive among blue-collar workers than among the white-collar workers.

Perioperative ultrasonography of lymph nodes in patients with gynaecological malignancy

OBJECTIVE

To examine the accuracy of perioperative ultrasonography in detecting pelvic and para-aortic lymph nodes, and to compare the ultrasonographic findings with those observed in histology.

PARTICIPANTS

Forty women with gynaecological malignancy were examined by ultrasonography during their operations before surgical exploration of the lymph nodes; 182 specimens were taken for histological analysis.

MAIN OUTCOME MEASURES

Ultrasonographic findings were compared with histological diagnoses of lymph node biopsies.

RESULTS

Suspicious lymph nodes (diameter > 5 mm) were found in 31 lymph node regions. Seventeen histologically malignant lymph nodes were found. The sensitivity, specificity, and accuracy of finding metastatic lymph nodes by ultrasonography were 71%, 88%, and 87%, respectively. The frequency of false negative ultrasonographic findings was 29%.

CONCLUSIONS

Perioperative ultrasonographic examination can be of use in localising pelvic and paraaortic lymph nodes, especially in laparoscopic operations, where tactile palpation of the retroperitoneal space is not possible. The negative predictive value of the method is high, but the relatively poor sensitivity limits its diagnostic value.

Does plasma L-arginine level play a role in regulation of blood pressure during exercise and autonomic nervous function?

Little is known of L-arginine's role in autonomic nervous regulation and physiological responses to dynamic exercise. We assessed heart rate and blood pressure during a maximal bicycle ergometer test and heart rate variability at rest in 15 healthy male volunteers, age 22-38 years. Venous blood samples for plasma L-arginine measurements were taken when subjects were sitting at rest before and at the end of exercise. The autonomic nervous function was assessed with time and frequency domain analysis of heart rate variability. Plasma L-arginine level decreased during maximal exercise from 71.4 mumol l-1 to 51.0 mumol l-1 (P < 0.0001) for all subjects studied. The systolic blood pressure during the maximal exercise test was inversely correlated with plasma L-arginine level at rest (r = -0.70, P < 0.01). Normalized low frequency band of power spectral analysis of heart rate variability correlated with L-arginine level at rest (r = 0.66, P < 0.01). In conclusion, plasma L-arginine level decreased in physical exercise, and plasma L-arginine level at rest was positively associated with the sympathetic component of power spectral analysis of heart rate variability at rest, and inversely with systolic blood pressure during physical exercise.

Lipid effects of an intrauterine levonorgestrel device or oral vs. vaginal natural progesterone in post-menopausal women treated with percutaneous estradiol

BACKGROUND

The ideal progestin for combined hormone replacement therapy should be free of adverse effects on lipid metabolism. We therefore examined lipid profiles during continuous hormone replacement therapy (HRT) with an estradiol-gel combined with either a levonorgestrel-releasing intrauterine device (LNG-IUD) or oral/vaginal natural progesterone.

METHODS

Sixty menopausal women recruited in this open, non-randomised parallel three-group study received percutaneous gel containing 1.5 mg of estradiol daily. Progestin was administered to the women with an LNG-IUD (n = 20), as oral natural progesterone (n = 21) 100 mg daily on the 1-25 calendar days of the month or as vaginal progesterone (n = 19) 100-200 mg daily on the 1-25 calendar days of the month. Serum concentrations for total cholesterol, LDL-cholesterol, HDL-cholesterol, triglycerides and sex hormone binding globulin (SHBG) were measured at 0, 6 and 12 months. The median (and 95% confidence interval) of the serum SHBG, total, LDL-, HDL- cholesterol and triglycerides concentrations at baseline and after 6 and 12 months of the study and the ratio of 6 and 12 months values to baseline values were calculated.

RESULTS

Total cholesterol was significantly decreased (8%) in the vaginal progesterone group at the end of the trial. HDL-cholesterol did not change in either of the progesterone groups, while a slight but transient decrease (median 15%) was seen at 6 months in the LNG-IUD group. There were no significant changes in triglycerides or LDL-cholesterol concentrations in any group. SHBG did not change significantly in the LNG-IUD and vaginal progesterone groups, while a slight but transient increase was seen in oral P group at 6 months.

CONCLUSIONS

As the only significant harmful effect observed was a transient decrease in HDL-cholesterol in the LNG-IUD group at 6 months, each of these HRT-administration methods can be regarded as being safe in their effects on lipid metabolism.

Ultrasonography of the ureter during laparoscopic, abdominal and radical hysterectomy

OBJECTIVE

To examine, by perioperative ultrasonography, ureteral anatomy and function during laparoscopic, abdominal and radical hysterectomy.

SUBJECTS

The study group consisted of 36 patients scheduled for laparoscopic, abdominal or radical hysterectomy; there were 12 patients in each group.

METHODS

The ureteral rest-phase diameter, maximal diameter during peristaltic waves and frequency of peristaltic waves were recorded immediately before and after hysterectomy under standard anesthetic conditions with the use of a 7.5-MHz linear laparoscopic ultrasound probe.

RESULTS

Ureteral peristaltic activity was decreased and the rest-phase diameter was increased after hysterectomy. The findings were most evident after radical hysterectomy with pelvic lymphadenectomy. Retrograde (cranial) flow was recorded in a majority of the patients. The individual variation was great, particularly after radical surgery. Short- and long-term clinical outcome was normal in all cases.

CONCLUSIONS

Uncomplicated hysterectomy is followed by changes in ureteral function. Although these changes apparently have no clinical significance, they must be recognized if laparoscopic ultrasonography is applied as a perioperative method to diagnose or exclude surgical ureteral lesions.

Whole-body vibration of tractor drivers during harrowing

The seat vibration of nine tractors was investigated while drivers harrowed fields in eastern Finland. The vibration acceleration of the tractor driver's seat was measured simultaneously along three mutually perpendicular axes. The triaxial seat-accelerometer was used for the measurements. The vibration signals were amplified with charge amplifiers and recorded with an FM tape recorder. The samples were analyzed with a real-time analyzer. In all cases, the average vibration of the seat exceeded the 8-hour "fatigue-decreased proficiency boundary" specified in the international standard ISO 2631/1. The instantaneous accelerations of the most harmful one-third octave band of vibration were sometimes two- to threefold compared with the average.

Endometrial morphology during hormone replacement therapy with estradiol gel combined to levonorgestrel-releasing intrauterine device or natural progesterone

OBJECTIVES

To evaluate endometrial responses to three different forms of amenorrhea-inducing HRT in postmenopausal women.

MATERIAL AND METHODS

Fifty-one postmenopausal women completing a one-year HRT trial with percutaneous estradiol gel containing 1.5 mg estradiol daily combined with a levonorgestrel-releasing intrauterine device (LNG-IUD) (n=18), or natural progesterone 100 mg daily orally (n= 19) or vaginally (n=15) during 1-25 calendar days of each month. Endometrial thickness and uterine size were measured by transvaginal ultrasound, and endometrial cytology/histology was assessed from specimens taken by needle aspiration before the study and at 12 months.

RESULTS

Before medication, the median endometrial thickness was 2.0 mm in the LNG-IUD group, 2.4 mm in the oral P group and 2.5 mm in the vaginal P group. At 12 months of therapy the respective values, 3.0, 2.7 and 2.4 mm, did not differ significantly from the initial values. LNG-IUD induced epithelial atrophy in all women, which was accompanied by stromal decidualization in 12 women. On the contrary, only four women in the oral P group and five women in the vaginal P group had an inactive or atrophic endometrium. The remaining cases were dominated by proliferative features. No hyperplasia was seen in any of the groups.

CONCLUSION

LNG-IUD appeared to be an effective method of counteracting the stimulatory effect of estrogen on the endometrium, whereas natural progesterone given orally or vaginally was not sufficiently effective in this function at the doses used. The vaginal and oral administrations of progesterone did not differ from each other in this respect.

Citalopram in the treatment of obsessive-compulsive disorder: an open pilot study

Obsessive-compulsive disorder (OCD) is a common anxiety disorder, which often causes significant impairment of the affected individual's social, occupational or interpersonal functioning. Previous reports suggest that the disorder may be treated with the tricyclic antidepressant clomipramine, and also with the more recently introduced selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine, fluvoxamine, sertraline and paroxetine. The present 24-week open pilot study was designed to examine the efficacy, appropriate dose range, side-effects and clinical usefulness of citalopram in OCD. A total of 29 OCD patients were included in the study, of whom 76% showed alleviation of symptoms as evaluated by various self- and observer-rated scales, such as the Yale-Brown Obsessive Compulsive Scale. In most cases the citalopram doses used were in most cases 40 or 60 mg daily, and the treatment was well tolerated. The most commonly experienced adverse events during the study were nausea, vomiting, increased dreaming and decreased sleep. Diminished sexual desire and orgasmic dysfunction were also reported. Despite having the limitations of an open study, our results suggest that citalopram may be effective in the treatment of obsessive-compulsive disorder.

Comparison of three serum assays for bone collagen formation during postmenopausal estrogen-progestin therapy

Postmenopausal hormone replacement therapy (HRT) lowers the turnover rate of the mineralized bone matrix, the predominant organic component of which is type I collagen. The effect of estrogen on bone metabolism has been monitored by measuring the circulating concentration of the carboxy-terminal propeptide of type I procollagen (PICP), which decreases during HRT. We have recently developed assays for the intact amino-terminal propeptide (PINP) of type I procollagen, a protein set free from the other end of the same gene product. PICP and PINP, both derived from the synthesis of type I collagen, but differing in their further metabolism, were assessed in 47 postmenopausal women, aged 45-66 years, undergoing postmenopausal HRT. Estradiol-gel applied daily was combined to a continuous progestin administered by three different routes. Serum samples obtained before the treatment and 6 and 12 months after its commencement were analyzed for PICP, PINP, PINP Col 1 (assay variant measuring also the degradation product of PINP) and PIIINP (amino-terminal propeptide of type III procollagen). During HRT the circulating concentration of PICP decreased by 20%, that of PINP by 42% and that of PINP Col 1 by 32% in 12 months. The correlation between the two propeptides, which was 0.676 before the treatment, increased to 0.851 in 6 months and to 0.815 in 12 months. The correlations between PINP and PINP Col 1 were 0.872 before the treatment and increased to 0.925 and 0.941 after 6 and 12 months of treatment, respectively. The serum concentration of PIIINP, which reflects the turnover of the soft tissue collagens, did not change remarkably. Our findings indicate that the intact PINP is a more dynamic marker of bone metabolism than PICP and can therefore be recommended as a marker reflecting the effect of estrogen on bone collagen formation during HRT.

Pregnancy in endurance athletes

The purpose of the present study was to examine pregnancy and delivery among Finnish endurance athletes at the national top level. A questionnaire concerning first pregnancy was sent to 30 Finnish endurance athletes who had been at national top level in cross-country skiing, running, speed-skating or orienteering. Data on labour were collected retrospectively through a questionnaire and from the diaries in the hospital concerned. The next primipara in the diaries formed a member of the control group. Twenty-three athletes (77%) had regular menstrual cycles, seven (23%) had irregularities, and four of them had received hormonal treatment for this. Seven athletes (23%) had experienced spontaneous abortion during the first trimester in previous pregnancy. Sixteen (53%) did not notice any change in their exercise performance, three (10%) subjectively felt themselves to be in a better physical condition, and seven (23%) felt themselves to be in a worse condition than before the pregnancy. Four did not respond on the question. After delivery, 18 athletes continued to compete, the median interval being 8.2 months (range 2-24 months). Two of them (11%) achieved a better condition than before the pregnancy, 11 (61%) reached the same level and five (28%) did not achieve the same performance level. There were no significant differences in labour parameters between the athletes and controls. Endurance training had no harmful side-effects on the pregnancies or deliveries of the athletes. The effect of pregnancy on exercise performance is individual.

Percutaneous estradiol gel with an intrauterine levonorgestrel releasing device or natural progesterone in hormone replacement therapy

OBJECTIVE

To evaluate the bleeding patterns and clinical compliance associated with postmenopausal amenorrhea-inducing forms of hormone replacement therapy using either percutaneous estradiol-gel and a levonorgestrel-releasing intrauterine device or an oral/vaginal natural progesterone.

METHODS

Sixty postmenopausal women with an intact uterus were followed over 12 months in this open, non-randomised, parallel group study. All patients continuously received a gel containing 1.5 mg of estradiol daily. The women were divided into three groups on the basis of progestin administration. Twenty women (group I) had a levonorgestrel-releasing device (LNG-IUD) inserted at the beginning of the study. Twenty-one women (group II) received oral natural micronised progesterone (oral P) 100 mg daily during 25 calendar days each month, and 19 women (group III) used vaginal natural micronised progesterone (vaginal P) 100-200 mg daily during 25 calendar days each month (higher dose if spotting occurred). Clinic visits were at 0, 3, 6 and 12 months. Bleeding patterns were recorded by the patient in a diary and clinical compliance was evaluated at control visits during the treatment. Symptoms were recorded using a modified Kuppermann index. The serum estradiol concentration was determined at the 0, 6 and 12 month control visits.

RESULTS

80% (n = 16) of the patients in the LNG-IUD group, 67% (n = 14) in the oral P group II and 53% (n = 10) in the vaginal P group were without bleeding at 12 months. Spotting was common during the first 3 months. Symptom relief was good in each group. The LNG-IUD did not cause any serious side-effects. Compliance was good for LNG-IUD and oral progesterone but not for vaginal progesterone.

CONCLUSIONS

Percutaneous estradiol-gel associated with LNG-IUD is an appropriate method of hormone replacement therapy. The combination of oral natural progesterone with estradiol-gel is also useful, although bleeding episodes complicated the treatment in one third of the patients. The vaginal administration of natural progesterone was impractical due to bleeding disorders.

Parameter evaluation of the differential diagnosis of female urinary incontinence for the construction of an expert system

Female urinary incontinence is a difficult problem for a patient but also for a physician. In the differential diagnosis of female urinary incontinence the physician has to determine a diagnostic class for the patient. This task is complex because of the unreliable patient history and the overlapping class boundaries. In order to develop an expert system to help the physician, a retrospective investigation on the incontinent women was performed to detect the potential expert system parameters. Also a diagnosis table was constructed from the expected values of parameters and the diagnostic classes. The results from K-means cluster analysis indicate that it is possible to develop the expert system on basis of the defined parameters and classes.

The effect of coenzyme Q10 on the exercise performance of cross-country skiers

Coenzyme Q10 supplementation (Bio-Qinon Pharma Nord, 90 mg/day) was studied in a double-blind cross-over study of 25 Finnish top-level cross-country skiers. With CoQ10 supplementation, all measured indexes of physical performance (AET, ANT and VO2Max) improved significantly. During verum supplementation, 94% of the athletes felt that the preparation had been beneficial in improving their performance and recovery time vs. only 33% in the placebo periods.

The risk of myocardial infarction among Finnish farmers seeking medical care for an infection

OBJECTIVES

This study determined whether people visiting a doctor because of infection had an increased risk of myocardial infarction.

METHODS

For 83 case patients and 249 matched control patients nested in a cohort of 3172 Finnish male farmers, comparisons were made on the basis of visits to a doctor because of infection.

RESULTS

Infections of the upper respiratory tract were statistically significantly associated with coronary artery disease. The odds ratio was 3.2 (95% confidence interval = 1.2, 8.5) for patients visiting a doctor four or more times because of infection of upper respiratory tract compared with patients with three or fewer visits.

CONCLUSION

Men in this sample with recurrent or chronic infections of the upper respiratory tract exhibited a pronounced risk for myocardial infarction.

Use of psychotropic drugs and risk of myocardial infarction: a case-control study in Finnish farmers

BACKGROUND

In 1992 Thorogood et al. reported an increased risk of myocardial infarction in women using psychotropic drugs. The aim of our study is to find out whether there is a link between the use of psychotropic drugs and subsequent myocardial infarction in males.

METHOD

A cohort of 3172 male farmers was followed from 1 February 1980 to 31 December 1992. Those subjects who had myocardial infarction without any previous symptoms during the follow-up were considered as cases. For every case three matched controls were selected. The matched variables were age, smoking habits, social status and county. The final sample includes 83 cases and 249 controls.

RESULTS

Those who had used psychotropic drugs had increased risk for myocardial infarction, odds ratio (OR) = 2.5, 95% confidence interval (CI):1.2-5.2. Most pronounced risk for myocardial infarction was found among users of anti-depressants, OR = 5.4 (CI:1.8-16.1).

CONCLUSION

The use of psychotropic drugs, especially antidepressants, is associated with increased risk of myocardial infarction. Further attempts are needed to determine whether the relationship between use of psychotropic drugs and risk of myocardial infarction is causal or not.

Risk of myocardial infarction among subjects visiting a doctor because of back disorder. A case--control study in Finnish farmers

STUDY DESIGN

A nested case-control study was made to analyze the correlation between back trouble and myocardial infarction.

OBJECTIVES

The purpose of the present study was to determine whether individuals visiting a doctor because of back trouble have an increased risk for myocardial infarction.

SUMMARY OF BACKGROUND DATA

According to previous results, back pain precedes myocardial infarction in young and middle-aged male farmers. There are no previous results concerning the risk of myocardial infarction among patients visiting a doctor because of back pain.

METHODS

The basic cohort includes 3172 Finnish farmers. Those having myocardial infarction from February 1, 1980 through December 31, 1992 were considered case studies. Three matched control subjects were selected for every case subject. The final group had 83 case subjects and 249 matched control subjects. Case subjects and control subjects were compared according to doctor visits because of back complaint during the follow-up period, which began February 1, 1980 and ended on the date of myocardial infarction of each case subject.

RESULTS

Fewer case subjects than control subjects visited a doctor because of back disorders during the follow-up period. This was especially true for nonspecific back pain (odds ratio = 0.51; confidence interval = 0.25-1.05).

CONCLUSION

Atherosclerosis is not a probable cause of any kind of back pain among individuals visiting a general practitioner because of back complaint.

High plasma interleukin-2: a potential cause of insulin resistance

Low-density lipoproteins, infections and smoking are closely associated with insulin resistance. According to the hypothesis proposed in this paper, all of these factors could cause insulin resistance by the same mechanism. The first step in the cascade of events leading to insulin resistance is increased production of interleukin-2. This is followed by secretion of other cytokines, activation of macrophages and increased production of nitric oxide from L-arginine. The reduced amount of plasma L-arginine leads to decreased secretion of growth hormone and insulin-like growth factor-1 during exercise. The decreased secretion of insulin-like growth factor-1 is the basic reason for insulin resistance. Tumour necrotizing factor may also be involved in the pathogenesis of insulin resistance directly by binding in beta-adrenergic receptors. High plasma interleukin-2 also causes decreased bioavailability of insulin-like growth factor-1 by reducing the production of androgenic hormones.

Insulin-like growth factor-binding protein-1: a biochemical marker of endometrial response to progestin during hormone replacement therapy

OBJECTIVES

To compare immunohistochemical localization of insulin-like growth factor binding protein-1 (IGFBP-1) in endometrial stromal cells with endometrial morphology during three regimens of continuous combined hormone replacement therapy.

METHODS

Endometrial samples for morphological examination and immunohistochemical staining with monoclonal antibody against IGFBP-1 were obtained from 30 menopausal women before treatment and after 12 and 24 months of continuous combined hormone replacement therapy. All women received percutaneous estradiolgel releasing 1.5 mg estradiol daily. Regarding progestins, patients were divided into three groups: one group (n = 15) had a 20 micrograms/24 h levonorgestrel-releasing intrauterine device (LNG-IUD); the women in the other two groups received micronised natural progesterone either 100 mg orally (n = 7) or 100-200 mg vaginally (n = 8) daily, 25 days per calendar month.

RESULTS

Before treatment the endometrium of all women was atrophic or subatrophic and no IGFBP-1 could be detected in any of the samples which contained enough stromal cells for evaluation. After 12 and 24 months of treatment, epithelial atrophy with decidual transformation in stroma was detected in all specimens in the LNG-IUD group, and IGFBP-1 was localized in decidualized stromal cells in all samples. In the other two groups, no signs of progestin effect were detected by microscopic examination in any of the endometrial samples and IGFBP-1 staining was completely negative in all of them.

CONCLUSION

A striking difference occurred in both morphological and biochemical response in the endometrium of women treated with LNG-IUD compared with those receiving oral or vaginal micronised progesterone during continuous combined HRT. Micronised progesterone at doses used in this study turned out to be ineffective to prevent the proliferative effect of estrogen. Immunohistochemical localization of IGFBP-1 in endometrial stromal cells strongly correlated with decidual reaction in all endometrial specimens exposed to LNG-IUD, suggesting that the immunostaining of IGFBP-1 can be used as a means of assessing the strength of progestin effect in the endometrium during HRT.

Hypothesis: low serum cholesterol, suicide, and interleukin-2

An excess mortality for violence (suicides and injuries) has been observed following the use of cholesterol-lowering drugs. It has been suggested that low cholesterol is associated with depression by modifying the serotonin metabolism. In this paper, a new hypothesis concerning the association among serum lipids, depression, and atherosclerosis is proposed. The hypothesis is based on epidemiologic evidence concerning serum lipids, depression, violent deaths, and atherosclerosis. It is also based on previous results concerning a cytokine, interleukin-2. Recent observations indicate that interleukin-2 has an important role in lipid metabolism, depression, and atherosclerosis.

Serum concentrations of CA 125 and aminoterminal propeptide of type III procollagen (PIIINP) in patients with endometrial carcinoma

Serum CA 125 (a marker of coelomic epithelial cells) and aminoterminal propeptide of type III procollagen (PIIINP; an indicator of collagen metabolism) concentrations were measured in 148 patients with endometrial carcinoma. An initial serum concentration of CA 125 was pathologic in 17% of the patients, the frequency of abnormal values being higher (P = 0.0001) in advanced (63%) than in early disease (10%). The serum PIIINP concentration was increased in 35% of the patients and more often (P less than 0.05) so in advanced (63%) than in early disease (31%). Among all the patients, at least one of the tumor markers was increased in 43% of the cases. In early disease 12 of 108 patients contracted recurrent cancer. The accuracy of the pathologic CA 125 (9%) and PIIINP (18%) concentrations in their prediction was poor. In the total material, pathologic CA 125 and PIIINP concentrations appeared simultaneously in 11 patients, of whom eight had poor prognoses. In monitoring of treatment response of 24 patients, regression was accompanied by normal or decreasing CA 125 and PIIINP values. The persistence of pathologic CA 125 and/or PIIINP concentration predicted relapse of the malignancy. In progressive disease, CA 125 and PIIINP concentrations together or separately remained at a pathologic level or increased continuously. In clinically stable endometrial carcinoma, CA 125 gave false-negative results in 71% of the determinations and PIIINP only in 12%. The current results suggest the use of CA 125 and PIIINP, simultaneously, in monitoring the clinical course of advanced endometrial carcinoma.

Simultaneous evaluation of epithelial cell function by CA 125 and stromal cell activity by aminoterminal propeptide of type III procollagen (PIIINP) in ovarian carcinoma

Serum concentrations of CA 125 and the aminoterminal propeptide of type III procollagen (PIIINP) were measured in 50 patients with clinical stage I or II (N = 16) and stage III or IV (N = 34) ovarian carcinoma before and during cytotoxic chemotherapy. Initially pathological concentrations of CA 125 were found in 92% of all patients and 100% of those in clinical stages II, III and IV. The concentration of PIIINP was at pathological levels in 71% of patients. Serum concentrations of CA 125 (P = 0.04) and PIIINP (P = 0.005) were higher in stages III and IV than in stages I and II. Initial concentration of PIIINP, but not of CA 125, was significantly (P less than or equal to 0.001) higher in the 19 patients who died of the malignancy than in the 31 patients alive at the end of the follow-up period. There was a significant inverse correlation (P = 0.01) between the initial PIIINP values and the survival time among patients with a poor prognosis. Initial concentration of CA 125 was of no prognostic value. During the follow-up, the serum concentrations of CA 125 and PIIINP correlated closely with clinical changes in the disease. Either or both of the tumour markers increased or remained at pathological levels before clinical relapse in patients who had initially responded. PIIINP was a more accurate marker (84%) than CA 125 (63%) in this respect. The information obtained from CA 125 and PIIINP concentrations was identical in 65% and complementary in 33% of the patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Farmers' occupational health program in Finland, 1979-1988: from research to practice

The Kuopio Regional Institute of Occupational Health, in collaboration with the Social Insurance Institution and the National Board of Health, conducted and evaluated a national model for the farmers' occupational health services. In January 1985 the National Board of Health instructed the Finnish municipal health centers to start the provision of farmers' occupational health services based on the recommendation given by the research group. The service was evaluated by experiments carried out during 1982, 1985, and 1986. The main problem in function of the services was that the health hazards (exposures) were difficult to observe and evaluate. The system of how the occupational health nurse evaluates the working conditions should be further developed. The efficiency of the services was studied by postal inquiries in 1982 and 1986. Farmers' knowledge about the appropriate means of reducing hazardous exposures had increased significantly due to the occupational health services. At the local level, the main problem in providing services for occupational farmers is that health centers do not have the resources to offer services for all farmers at the same time. Altogether by the end of 1986, about 30% of all active farmers in Finland (45,000 farmers) were willing to have occupational health services, which is voluntary for self-employed farmers.

Gonadotropin-releasing hormone agonist analog therapy effective in ovarian granulosa cell malignancy

Ovarian granulosa cell tumor lung metastases regressed, and symptoms were relieved, during gonadotropin-releasing hormone (GnRH) agonist analog therapy after the failure of operative treatment and cytotoxic chemotherapy, indicating the hormone dependence of the malignancy. The response was transient, but the largest metastasis did not relapse. This case report suggests that GnRH analogs may offer a new approach to the treatment of ovarian stromal cell malignancies.

Urethral pressure variations diagnosed by multiple urethral pressure transducers. A common phenomenon in women suffering from urinary incontinence

The prevalence of urethral pressure variations (variation of urethral pressure greater than 15 cm H2O) was investigated, with the use of a data-based multitransducer catheter, in female patients suffering from urinary incontinence. Urethral pressure variations were diagnosed in 45 (63%) of 71 patients. This prevalence was greater than in previous studies, possibly for methodological reasons; the urethral pressure was simultaneously measured by five urethral microtransducers, thereby registering all variations in maximal urethral pressure. The present method also showed that urethral pressure variations were simultaneously present in different urethral sites, but that the amplitude of variation differed between the different points of registration. In most cases, urethral pressure variations were already apparent at the start of urethrocystometry. Voluntary holding, in an effort to inhibit the desire to void, can cause these variations in urethral pressure. Hence urethral pressure variations may be a normal physiological phenomenon.

Successful colposuspension in stress urinary incontinence reduces bladder neck mobility and increases pressure transmission to the urethra

Twenty-nine consecutive patients with stress urinary incontinence were investigated by bead chain urethrocystography (UCG) and single cough urethrocystometry before operation and 8-12 months after a Burch colposuspension producing clinical improvement. The operation significantly elevated the bladder neck and reduced its mobility during acute stress. The urethral inclination angle and the posterior urethrovesical angle also became smaller at rest and on straining. A significant negative correlation was found between the postoperative mobility of the bladder neck and the post-operative pressure transmission ratio (PTR), indicating that correction of the urethrovesical anatomical disorder eliminates the functional disorder in this disease and restores continence.

Effect of suprapubic operation on urethral closure. Evaluation by single cough urethrocystometry

To evaluate urodynamic effects of modified Burch colposuspension, 24 patients with stress urinary incontinence were investigated before and 6 to 9 months after the operation. A new method of urodynamic evaluation was performed using a multitransducer-catheter, 5 microtransducers inside the urethra and 1 in the bladder, connected to a computer and graphic plotter. Single coughs were analysed with the catheter in a fixed position and the patient in the standing position. The operation, which was successful, in all but 1 patient, did not alter urethral pressure at rest, but urethral closure pressure at stress after the operation (mean 45.0 cm H2O (SD 21.6) was significantly higher (P less than 0.005) than the -3.6 cm H2O (SD 10.2) recorded before the operation. The pressure transmission ratio was less than 100% in 22 patients before the operation and more than 100% in 18 patients afterwards, the pre- and post-operative mean values being 78.9% (SD 11.9) and 109.5% (SD 17.2) respectively (P less than 0.0005). Burch colposuspension markedly improves urethral closure function as evaluated by this method, which analyses the pressure data at different points of the urethra and bladder during one single cough.

Six-microtransducer catheter connected to computer in evaluation of urethral closure function of women

A new instrument consisting of a six-transducer catheter, one transducer for the bladder and five transducers for urethral pressure recordings, and a computer with specific software was developed for urodynamic investigation of women. Twenty-six patients with stress urinary incontinence (SUI) and 10 continent female patients were evaluated during the single cough, the first and the fourth ones of the forced coughings in supine and standing positions. The results were compared with those obtained with the conventional two-transducer method. Negative urethral closure pressure (UCP) at stress, indicative of SUI, was present in 88 percent of the cases with the six-transducer method, and in 77 percent with the two-transducer method. The fourth cough in the standing position with the six-transducer method was most diagnostic. In SUI, the six-transducer method indicated exactly, e.g., the minimum bladder pressure needed for negative UCP and the duration of negative UCP. Patients with SUI had significantly lower UCP at rest, UCP at stress, and pressure transmission ratio (PTR) than continent women. Findings, that UCP at stress decreased and duration of negative UCP at stress increased but PTR did not change when the fourth cough was compared with the first one in SUI, suggest that factors which are responsible for the altered urodynamics during prolonged stress are anatomic rather than functional.

Colposuspension and transvaginal bladder neck suspension in the treatment of stress incontinence

The present work was performed to evaluate the clinical usefulness of colposuspension in stress urinary incontinence without uterovaginal descent and bladder neck suspension in cases with uterovaginal descent. Modified Burch colposuspension was performed in 29 patients and modified Raz bladder neck suspension in 19 patients. The patients were examined clinically and urodynamically before and 8-12 months after operation. All patients in the colposuspension group regarded themselves as being totally continent postoperatively. In the bladder neck suspension group the respective figure was 58%, plus 21% showing improvement and 21% failures. Urodynamically, the cure rates (positive urethral closure pressure at stress) were 100% for colposuspension and 79% for bladder neck suspension. After colposuspension the urethral closure pressure at stress and the pressure transmission ratio were significantly increased whereas successful bladder neck suspension increased only urethral closure pressure at stress. The failed bladder neck suspensions did not induce any urodynamic changes. The present data confirms that Burch colposuspension is effective in stress urinary incontinence in women without simultaneous uterovaginal descent, whereas bladder neck suspension by the modified Raz technique did not appear to be optimal for the treatment of stress incontinence in patients with uterovaginal descent.

Histologically demonstrable vital reactions to frostbite in guinea pigs dying of hypothermia

Vital reactions in the paw skin of guinea pigs dying of hypothermia were examined using a variety of histochemical methods to find ways of distinguishing between ante-mortem and post-mortem frostbites. Some animals were treated with ethanol or diazepam. Edema, hyperemia, and incipient accumulation of granulocytes were seen to develop within the 2-6 h for which the animals had survived in the cold (-20 degrees C). The granulocytes were first seen in the capillaries beneath the epithelial papillae and thereafter deeper in the dermis. They mostly accumulated inside the venules in the endothelium, but there were cases in which emigration had started. The best method for demonstrating the reaction appeared to be the alkaline phosphatase reaction, which is strong in guinea pig granulocytes and highlighted the latter well against a negative background. The conclusion is that it is possible to detect a positive vital reaction, but methodologic investigations are needed before similar changes can be visualized in cases of acute hypothermia in human beings.

Epidemiological evidence for two components of cervical cancer

Incidence rates for cervical cancer were analyzed for Finland in 1953 to 1974. The age-specific incidence rates fit an age-incidence curve based on the assumption of two epidemiological components. The time trends give support to the hypothesis that one of the components occurs at a lower age and is preceded by a carcinoma in situ stage. The risk of cervical cancer originating from the component occurring in younger women showed a decreasing trend which correlated with the organized mass screening programme. The other component occurred later in life and was not influenced by the screening programme. It was estimated that the proportion of the cases in the earlier category decreased from 53% in the 1950s to 17% in 1973 to 1974 of all cases of cervical cancer diagnosed in the Finnish population.

The effect of ethanol and cold-adaptation on the survival of guinea pigs in severe cold

An acute ethanol dose of 2 g/kg shortened the survival time at -20 degrees C of guinea pigs both adapted to the cold and those reared in the warm, but no significant difference was observed between the adapted and non-adapted groups. Long-term ethanol treatment of 2 g/kg/day for 4 weeks, lengthened the survival time of the guinea pigs reared at room temperature, but did not affect the survival of the cold-adapted animals. The acute dose of 2 g/kg shortened the survival time of the guinea pigs which had received the 4-week ethanol treatment and had been reared in the warm, but did not have the same effect on the cold-adapted animals. The improved survival rate at severe exposure acquired by adaptation to the cold was abolished by chronic alcohol administration.

Changes in the myocardium and skeletal muscle in guinea pigs in cold exposure with and without ethanol

The effect of hypothermia with and without ethanol on the myocardium and skeletal muscle was studied. Changes were observed in both muscle types. The mildest lesions were discoloration of the muscle cells with acid fuchsin and Heidenhain's iron haematoxylin staining, these being more marked in the skeletal muscle. Waving and contraction bands in the muscle were seen in hypothermia. The most severe lesion was a focus with oedema and haemorrhage, a reduced reaction of beta-hydroxybutyrate dehydrogenase and fragmentation of the muscle cells, and this was more frequent in the myocardium. Occasionally discoloration, contraction bands and waving were also seen in the controls killed by a blow on the neck. The changes were more numerous in the guinea pigs given ethanol before cold exposure, and serum creatinine phosphokinase was elevated in the same group. Urinary excretion of adrenaline increased in cold exposure, but noradrenaline did not change significantly. Hypoxia, catecholamines, and sludging of the blood are discussed as possible aetiological factors for the lesions.

Effect of progesterone treatment on the development and function of neonatal rat adrenals and testes

The high progesterone (P) level of pregnancy was mimicked in neonatal male rats. The rats received 10, 30 or 100 microgram/g body weight of P in daily subcutaneous injections for 1, 2 or 3 weeks. It was expected that the treatment would yield developmental and functional changes similar to those possibly occurring under the influene of P in utero. P did not significantly affect the body weights of the animals, but significantly decreased the weights of the adrenals. Testicular weight was increased in the P-treated rats, and the number of Leydig cells was higher than in the controls. Peripheral serum testosterone and corticosterone, and testicular testosterone levels were only slightly decreased by the treatment. The changes observed in these neonatal animals suggest a regulatory function for P in the development of the fetal adrenal gland and testis.